Evidence-Based Reviews

What to do if you—or a patient—is a victim of stalking

Psychiatrists are often subject to obsessive pursuit by patients because of their unique therapeutic relationship. A patient of yours may also have been a stalking victim at some point. Here is vital advice on identifying stalking behaviors early and guarding against unwanted advances.

About 1.4 million people are stalked each year in the United States.1 Chances are you or one of your patients have been among that statistic.

In the U.S., 8% to 12 % of adult women and 2% to 4% of adult men have been stalked at some point in their lives.2 While celebrities and politicians tend to be high-profile targets, psychiatrists and other health-care professionals may find themselves subject to unwanted contact or obsessive pursuit; this may be because psychiatrists are perceived to be warm, caring, or nurturing. Also, mental health professionals regularly see patients who are particularly prone to engaging in stalking behaviors.

As a former forensic psychiatry fellow, I have studied the risks and patterns of stalking in an effort to help victims of stalkers protect themselves and use legal remedies when appropriate.

The objectives of this article are threefold:

To identify the unique problem of a patient stalking a psychiatrist and how to cope.

To address what every stalking victim (including a patient) can do to protect herself or himself.

To provide basic definitions of stalking and to outline the current, most widely accepted clinical classification of stalkers and its relevance in predicting the stalker’s response to legal and/or mental health interventions. All 50 states and the District of Columbia have passed laws specifically criminalizing stalking.3

When a psychiatrist is stalked

In her book, I Know You Really Love Me,4 psychiatrist Doreen Orion, MD, recounts her experience as a stalking victim. Her victimization began in 1989, when she was on night call for a psychiatric hospital in Arizona. One of the patients she admitted that night was Fran, who developed the erotomanic delusion that Dr. Orion loved her. Despite all evidence to the contrary, Fran pursued Dr. Orion for nearly 8 years, even following her to another state.

Dr. Orion’s book illustrates several issues of import, starting with a crucial failure to communicate. The following morning, Dr. Orion went to the psychiatric hospital to evaluate the patients she had admitted the night before. She contacted Fran’s treating psychiatrist, who angrily hung up on Dr. Orion because Fran had been admitted to the “wrong hospital.” He neglected to inform Dr. Orion that Fran had a history of same-sex stalking and erotomanic delusions. Had she been informed of Fran’s stalking patterns. Dr. Orion may have then simply transferred Fran’s care to a male colleague.

Ultimately, some of Dr. Orion’s colleagues viewed her as somehow inviting or being at fault for her stalking victimization. This classic “blaming the victim” aggravated a situation that was already maddening enough. (Eventually, after several legal and psychiatric evaluations, the stalking stopped.)

Dr. Orion’s book is a cautionary tale. Knowing the patient’s history by reviewing prior records and contacting former treating clinicians can uncover a past pattern of stalking. However, as we are well aware today, terrorists may not become known as such until their first terrorist act; with stalkers, a previous pattern may not be apparent in some cases.

It is important to recognize stalking behaviors for what they are and to act quickly. As psychiatrists, we may be more able than other clinicians to do this because we are trained to ask the patient questions, then simultaneously observe and monitor both the patient’s behavior and our reactions to it. Gavin DeBecker’s book, The Gift of Fear,5 details the survival properties of being in tune with one’s fear response as protective.

Typically, stalking has an insidious onset and may even seem initially harmless, perhaps noted as an erotic transference. But you must pay attention to the behavior and how it makes you feel. Be aware that it may escalate and be prepared to take measures to protect yourself.

Questions to ask yourself might include:

What are your clinical impressions?

Are axis I and/or axis II disorders present that may respond to treatment?

Is your therapeutic relationship with the patient fairly new, or is this an established doctor-patient relationship?

Is the patient an otherwise stable person who is under stress and engaging in uncharacteristic behavior?

Consider the answers carefully, bearing in mind the typology or typologies involved (Table 1). Stalking encompasses a continuum of unwanted behaviors, ranging from the innocuous to overt and harmful stalking. Your clinical decision-making depends on the typology and intensity of the behavior, as well as your own tolerance for such behaviors.

Table 1

STALKER CLASSIFICATION SYSTEM*

Type

Features

Assault potential

Response to legal interventions

Response to mental health interventions

Rejected

Response to an unwelcome end to relationshipSeeks to maintain the relationship Long duration

Along with Predatory, the most likely to assault

Will usually curb behaviors

Typically not responsive to therapy

Resentful

Response to a perceived insultSeeks vindicationSelf-righteous and self-pitying

Most likely to threaten, least likely to assault

Will usually stop behaviors

Difficult to engage in therapyFocus on ruminations that drive stalkers

Intimacy seeking

Belief that they are loved or will be loved by the victimSatisfies need for contact and feeds fantasies of eventual loving relationship

Interestingly, a female patient also exhibited unwanted behavior toward Dr. Orion’s psychiatrist husband. This patient frequently parked in front of their home in the evenings. Unlike Fran, whose stalking behaviors became increasingly intrusive, frightening, and violent, this patient did not escalate her behavior. It was an unwanted intrusion, but he did not feel fearful or victimized by it. Therefore, it didn’t meet the clinical or legal definition of stalking—the unwanted behaviors must produce fear in the victim. Another psychiatrist, however, might consider the same scenario to be fearful.

Terminating the therapeutic relationship

Once you have reviewed the case with a colleague and/or a threat-assessment professional and determined that you feel uncomfortable and unsafe, it’s time to terminate the doctor-patient relationship.

Ethical and professional care dictates that you provide the patient with a reasonable written notice (e.g., 30 days) prior to termination. Three referral options with phone numbers are typically provided. This also protects you from a potential malpractice tort of abandonment while the patient still needs treatment. If you sense possibly imminent danger, however, you may need to abbreviate the 30-day notice.

Write a summary note in the patient’s chart that includes, in addition to the usual case summary components, the following:

Your reason(s) for termination. Include discussion with colleagues and/or threat assessment or law enforcement professionals;

Your diagnostic and treatment impressions, the treatment provided, and the patient’s response to treatment;

Your referral choices and the rationale for those decisions, e.g., “female patient with schizophrenia and erotomanic delusions and a history of same-sex stalking referred to a male psychiatrist.” The referral should be made to an outside agency or system. (Once Dr. Orion realized that she was being stalked, she initially made the mistake of transferring her patient to a male colleague who shared her office suite, thus making it easy for Fran to continue to stalk Dr. Orion in her own office.)

Documentation of your discussion with professionals to whom you are referring the patient, along with the patient’s release of information permitting you to do so.

Documentation of your discussion with the patient. If applicable, include your statement that you feel it is in the patient’s best interest to continue psychiatric care.

A copy of the termination letter.

If the stalking persists, the psychiatrist should follow guidelines for victims provided later in this article.

J.P. and his ‘ex-girlfriend’

J.P., 19, met Ms. T. when both were 16 and still in high school. Ms. T. was a “partying friend”; they smoked pot together and “hung out.” Although they never dated nor had a romantic relationship, J.P. found Ms. T. to be “pretty and fun,” and developed secret romantic feelings for her.

In their senior year, J.P. wrote Ms. T. a letter professing his love for her. She laughed at it, was dismissive of his feelings, and shared it with friends. He subsequently felt humiliated and rejected and, in retaliation, began spreading rumors that she was a “witch” and a “lesbian.”

After their graduation, they saw each other on a few occasions at parties, but rarely spoke. About a year and a half later, J.P. saw Ms T. with a man he had once fought. He regarded this man as “no good” and a poor choice on Ms. T.’s part. He obtained her phone number from one of their mutual high school acquaintances and called her. They spoke briefly; he accused her of “using drugs and dating an asshole.”

Whether to change a phone line. One recommendation is to maintain the phone line with an answering machine turned down and let the stalker call it. The victim then obtains another phone line and gives the number only to select friends, colleagues, etc. This way the stalker has a venue for self-expression but the victim does not have to listen to it. Law enforcement can be given the tapes for review. By allowing the stalker continued access to the phone line, the stalker does not have to seek out other potentially more violent ways to pursue his or her victim.

Whether to seek a restraining order. There is some disagreement on whether restraining orders are useful. In some cases, a restraining order may escalate the situation, such as with prior intimates. In other situations, it may give the victim a false sense of security and ultimately may be of little use if the stalker violates it. When the stalker violates a restraining order and experiences no significant painful consequences, this can increase his sense of power and correspondingly reduce that of the victim.

Thus began a pattern of unwanted phone calls and letters left through the mail slot of her parents’ front door and on her car windshield. One letter featured a drawing of 2 tombstones, one with his name and one with hers, with R.I.P. (Rot In Pieces) scrawled below her tombstone. When asked how he thought she might respond to this, J.P. shrugged and explained it was “funny.” He claimed he was “just imitating Eminem,” a well-known “badboy” rapper who has a similar tattoo on his abdomen.

One letter indicated his desire to become a professional baseball player and his belief that if he had her love, he could succeed at this endeavor. He seemed unaffected by her lack of interest in him.

An early refill request for psychostimulants for your college-age patient

﻿Mr. R, age 18, who has been taking amphetamine/dextroamphetamine, 10 mg/d, twice a day, for attention-deficit/hyperactivity disorder since he was age 10, comes to see you shortly after beginning college asking to refill earlier than usual. He says his symptoms are worse since beginning college and he is finding it difficult to focus in class and keep up with the heavy course work. He says he has been taking an extra 10 mg when he “needs the extra boost.” He asks for an early refill and increased dosage. How do you proceed?

Switch to an extended release formulation and increase the dosage to 30 mg/d

Switch to lisdexamfetamine, 30 mg/d

Prescribe amphetamine/dextroamphetamine, 10 mg, on an as-needed basis

Tell Mr. R to take his current prescription as prescribed and discuss the dangers of stimulant abuse. Reassess his symptoms at the next visit.